Rhinoplasty Operating Room Footage – Turbinate Reduction (Nose Job)
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Enter the operating room with Rhinoplasty Specialist Dr. Paul Nassif, a world-renowned expert in revision & ethnic rhinoplasty, as he performs a Turbinate Reduction. His practice, Spalding Drive Cosmetic Surgery & Dermatology, is located in Beverly Hills, CA.
In anatomy, a nasal concha (or turbinate) is a long, narrow and curled bone shelf (shaped like an elongated sea-shell) which protrudes into the breathing passage of the nose. Turbinate bone refers to any of the scrolled spongy bones of the nasal passages in humans and other vertebrates. [1]
In humans, the turbinates divide the nasal airway into three groove-like air passages and are responsible for forcing inhaled air to flow in a steady, regular pattern around the largest possible surface of cilia and climate controlling tissue.
It can be performed under a general anesthetic or with local anesthetic. Incisions are made inside the nostrils (closed rhinoplasty). Sometimes, a tiny, inconspicuous incision is also made across the columella, the bit of skin that separates the nostrils (open rhinoplasty). The surgeon first separates soft tissues of the nose from the underlying structures, then reshapes the cartilage and bone. Most people remain at home for a week. If there are external sutures, they are usually removed 4 to 5 days after surgery. The external cast is removed at one week. If there are internal stents, they are usually removed at four days to two weeks. The periorbital bruising usually lasts two weeks. Due to wound healing, there are minor and subtle shifting and settling of the nose over the first year.
In some cases, the surgeon may shape a small piece of the patient’s own cartilage or bone to strengthen or change the structure of the nose. Usually the cartilage is harvested from the septum although if there isn’t enough which can often occur in revision rhinoplasty, cartilage can be taken from the concha of the ear or rarely the ribs. In the rare case, again usually revision rhinoplasty, where bone is required, it is harvested from the cranium or ribs. Sometimes a synthetic implant may be used to reconstruct the nose. This is most common when augmenting the bridge of Asian noses.
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Duration : 0:1:53
Operating Room Footage – Septoplasty for Rhinoplasty
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Septoplasty is a corrective surgical procedure done to straighten the nasal septum, the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Often the inferior turbinate on the opposite side enlarges, which is termed compensatory hypertrophy. Nasal obstructions caused by serious deviations frequently lead to chronic sinus problems. Turbinate reduction may also be advised to further enlarge the nasal cavities. If turbinate resection is indicated special care should be taken to avoid over-resection leading to Empty nose syndrome. Most surgeries are completed in 90 minutes or less, not including recovery time.
Every year, half a million people who are interested in improving the appearance of their nose seek a consultation with a Facial Plastic Surgeon. Some are unhappy with the nose they were born with, and some with the way aging has changed their nose. For others, breathing may be a problem, or an injury may have distorted the nose. A slight alteration of the nose can greatly improve ones appearance. Rhinoplasty (reshaping the nose), could improve ones looks, self-confidence or health. As with all facial plastic surgery, good health and realistic expectations are prerequisites.
The goal of rhinoplasty is to improve the nose aesthetically (without creating a surgical look) in order to create harmony with other facial features. Additionally, many patients have a chin augmentation in conjunction with rhinoplasty to create a better balance of features. Rhinoplasty is usually performed with local injections of anesthesia with intravenous sedation, or in some cases, under general anesthesia.In rhinoplasty, the majority of incisions are made inside the nose, where they are invisible. In some cases, an incision is made in the area of skin separating the nostrils. Certain amounts of bone and cartilage are then removed or rearranged to provide a newly shaped nose. If the patient has a deviated septum (cartilage and/or bone causing obstruction inside the nose), septal surgery, called septoplasty, is simultaneously performed. The incision is placed entirely inside the nose. The septoplasty removes portions of cartilage and/or bone that are causing the obstruction. The incisions are then closed with fine suture, followed by placement of a splint to the outside of the nose. The splint helps retain the new shape while the nose heals.
Duration : 0:1:37
Operating Room Footage – Deep Temporalis Fascia for Rhinoplasty
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Another important detail is to ascertain if you have nasal obstruction. I will determine if the nasal obstruction was present preoperatively. If the obstruction is a result of the surgery, a number of questions need to be answered. Did you have reductive rhinoplasty surgery? I will have you point out where the obstruction is. Is it static or dynamic? Present with normal or deep inspiration? What alleviates and worsens the nasal obstruction? What are the characteristics of the nasal obstruction? Was septal surgery performed? With these important questions answered I am now ready to perform the physical examination.
For the physical exam, I use a detailed nasal analysis worksheet. I will perform a detailed visual and tactile evaluation of the nose. For the bony dorsum, I will examine the osteotomies, presence of open roof deformity or rocker deformity, and hump under- or over- resection (Figures 7a – Before, 7b – After and 8a – Before, 8b – After). Then I will examine the middle part of your nose, called the middle vault. I will look for middle vault abnormalities such as a narrow middle vault, inverted V deformity or under-resection of the caudal cartilaginous dorsum (Polly beak deformity). For the tip, I will examine tip projection, rotation, support, alar and columellar retraction, over aggressive Weir incisions, and lower lateral crural characteristics such as over-resection, cephalically oriented or bossae formation (Figures 9a – Before & 9b – After, 10a – Before, 10b – After). Over-resection of the lower lateral cartilage complex in patients with a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and nasal obstruction (Figures 11a – Before, 11b – After & 12a – Before, 12b – After ). This problem often occurs in Hispanic, Asian, Middle Eastern and African-American patients. A deviated cartilaginous dorsum and tip can signify a deviated septum. This is only a partial list of anatomical problems that I need to identify in nasal analysis.
For patients with nasal obstruction, Ill observe you performing normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable as supra-alar, alar and/or rim collapse or slit-like nostrils during static or dynamic states. External Valve Collapse (lower lateral cartilage pathology) can be evaluated with the soft end of a cotton swab while plugging the contra-lateral nostril. The cotton swab elevates the area of obstruction whether its the alar rim, lower lateral crura or supra-alar region. I will see if the nasal obstruction is alleviated by elevating the nasal tip in patients with ptosis of the nasal tip. I will perform the Cottle maneuver (pulling laterally on the cheek) to check for internal valve collapse. Although this test is generally non-specific, internal nasal valve pathology caused by supra-alar pinching or a narrowed angle between the upper lateral cartilage and septum can be diagnosed. On basal view, Ill examine the medial crura to identify if they are impinging into the nasal airway. Following a thorough external nasal evaluation, I will examine the inside of your nose. I will examine your nose with a nasal speculum and check the nasal septum for perforations, persistent deviation (Figure 13) and for any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae (scar bands) between the lateral nasal wall and septum, nasal masses and middle turbinate abnormalities (concha bullosa).
Duration : 0:2:27